Does your hospital’s clinical documentation improvement (CDI) program concentrate on cases in which the insurance carrier pays based on the Medicare severity diagnosis-related group (MS-DRG) system? I mention hospital because the typical CDI program is facility based, focuses on inpatients, and works diligently to ensure that all diagnoses affecting its MS-DRG payments are clearly documented and clinically supported in the chart before the case goes to coding.

If an organization is fortunate enough to be well staffed, well funded, and able to review all inpatient cases regardless of payer, it is to be congratulated. Many still focus only on MS-DRG payers, querying physicians when the expected clarification of a diagnosis or procedure will increase hospital payment and moving on to the next case when the effort likely would not yield any return on investment.

This certainly is a critical undertaking. The need has created a career—a credentialed profession, no less—that did not exist 25 years ago. The question to be asked is whether the profession is keeping up with the ever-changing structure of the payment system that created it.

Remember Newton?
Not all queries will increase the payment for the case at hand; some will affect only the severity-of-illness or risk-of-mortality indicators. Be aware that several state Medicaid agencies are paying hospitals based on the all-patient refined (APR-DRG) system, which assigns payment on a case’s severity of illness instead of the average cost of care—the same method used in the MS-DRG system.

Hospital comparisons that proclaim “you’re twice as likely to die of a stroke at Hospital A than at Hospital B” or “Hospital B can take care of much sicker patients than Hospital A” are based on the severity of illness and risk of mortality from the APR-DRG system. Are CDI reviewers trained about and querying for clarification on these diagnoses?

Consider Newton’s Third Law: For every action, there’s an equal and opposite reaction. How does that axiom apply to CDI? Uncontrolled diabetes once was a complication or comorbidity (CC), a significant secondary diagnosis that affected payment in the DRG system. Physicians constantly were queried to clarify whether poor control meant uncontrolled. They quickly learned that regularly documenting when a patient’s diabetes was uncontrolled would end those sticky notes and e-mails from CDI specialists.

Eventually, uncontrolled diabetes was pulled from the list of significant secondary conditions that affected payment. Why? When it rarely was documented, the statistics showed that patients with uncontrolled diabetes were among the more expensive cases. Thus, a CC was created. Then the diagnosis became so common that these patients were no longer always the more expensive cases; the statistical population became diluted, as it were. Subsequently, the CC was removed.

The same situation occurred with dehydration and the associated diagnosis of acute kidney injury. The former was documented so often that it no longer generated a CC, while the latter debuted on the major CC list but soon dropped to the regular CC list—and even there, its existence is tenuous.

Per Newton, for every action, there’s an equal and opposite reaction.

Sepsis and Chest Pain
Similar circumstances surrounded CDI programs’ efforts to document sepsis. They may have recorded and coded sepsis instead of urosepsis, postoperative infections instead of inflammation and treatment with antibiotics, or possible pneumonia rather than upper respiratory infection with an infiltrate on the chest X-ray. As a result, payments spiked, along with the amount of documentation.

Was this incorrect? Of course not. Did anyone entice physicians to document conditions that really didn’t exist in order to improve reimbursement? Perhaps, but most CDI specialists are careful to produce compliant, nonleading clarification requests.

Today, the Centers for Medicare & Medicaid Services (CMS) continues to expand its pay-for-performance programs, reducing payments to hospitals that have poor quality indicators, which are derived from—you guessed it—statistics culled from diagnosis and procedure codes.

These abundantly documented CCs are raising questions about quality of care. Was the patient coded as possible pneumonia readmitted within 30 days? Did a postoperative infection diagnosis create concerns about the surgeon’s competency or that postoperative care was lacking?

What about that chest pain patient who had an acute myocardial infarction documented in the emergency department but later had a normal electrocardiogram and a negative cardiac catheterization? A CDI reviewer may think, “What a great DRG!” and choose not to query the physician and risk losing a juicy payment. But did the case subsequently create a failure in core measures data reporting when the treatment expected for an acute myocardial infarction was not provided?

Gather All Info
Similar quandaries arise when a CDI reviewer must decide whether querying for clarification will improve quality reporting but reduce payment or when not querying will improve payment by keeping a major secondary diagnosis but cause a patient’s medical history to report an incorrect diagnosis. A typical example is a sepsis or cancer diagnosis that may have been presumed at admission but then seems to have been ruled out by tests or pathology.

A CDI reviewer may be faced with abnormal lab results, implying that a patient has developed a postoperative infection. Will the fact that confirmation of the diagnosis may reflect poorly on quality of care create pressure to withhold the query? After all, a CC or major CC may raise the payment for one case, but accrue too many poor quality indicators and the hospital faces losing as much as 2% of its annual Medicare payment.

Should the CDI department be checking for present on admission from the list of potentially preventable hospital-acquired conditions? If surgeries are taking longer than the national average or if there is concern about readmission rates and wound dehiscence or infection, is anyone making sure that contributing factors are being documented and coded? Noncompliance with antibiotics, being homeless, lacking the financial means to keep medical appointments, substance abuse, malnutrition, and morbid obesity generally don’t affect a DRG payment, but they certainly can influence surgery’s effectiveness which, in turn, may increase the possibility of readmission as well as postoperative complications such as infections and dehiscence.

If the provider documents that these circumstances affected care, then coding can report them along with the rest of the patient’s problems. Thorough documentation may provide substantive data for public reporting when the CMS is deciding which complications may be due to factors other than poor care.

Most health care organizations can’t do anything about the decisions made by the government and insurance companies when analyzing public data. However, they can ensure that what’s reported publicly is not only accurate but also complete in explaining what happened to a patient and why.

The CDI profession may have been born out of the DRG payment system, but today it can—and should—be much more. It can impact inpatient DRGs, outpatient payments, support for medical necessity, core measures, surgical quality of care, and even clinical support for the level of billing complexity. The list seems endless.

Don’t confine the CDI team to reviewing and querying only for diagnoses that affect payments on MS-DRG payers. For the good of an organization and its patients, allow the staff to provide detailed and accurate documentation on all diagnoses and procedures.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 22 years.